Legal Business Name :

Business Type :   Proprietorship    Partnership   Corporation   LLC     Government   Trust    Non-Profit

Business Contact Name :

Address :

City :

State :

Zip :

Cell :

Phone :

Fax :

Email :

Website :

Current Financial Statement or balance Sheet Attached? :   Yes     No  

If no, Explain :

Type of Business :

How long in business :   Years

If Subsidiary, Name of Parent Company :

The above business name adopted by the undersigned, which is/are jointly and severally responsible for all goods, ordered in this name we agree to notify you immediately in writing of any changes in ownership or partnership

Name :

Phone :

Address :

City :

State :

Zip :

Bank Name :

Bank Address :

Phone :

City :

State :

Zip :

Company Name :

Contact Name :

Type of Account :

Phone :

Email :

Fax :

Company Name :

Contact Name :

Type of Account :

Phone :

Email :

Fax :

Company Name :

Contact Name :

Type of Account :

Phone :

Email :

Fax :